A variety of interventions have been described for the treatment of low back pain, and it is not the intention of these clinical practice guidelines to exhaustively review all interventions.
Instead these guidelines focus on approaches in which randomized, controlled trials and/or systematic reviews that have tested these interventions in environments that would match physical therapy application. In keeping with the overall theme of these guidelines we are focusing on the peer-review literature and making recommendations related to 1) treatment
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matched to subgroup responder categories, 2) treatments that have evidence to prevent recurrence, and 3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.
It is believed that early physical therapy intervention can help reduce the risk of conversion of patients with acute low back pain to patients with chronic symptoms. A study by Linton demonstrated that early active physical therapy intervention for patients with the first episode of acute musculoskeletal pain significantly decreased the incidence of chronic pain.195 This study represented a cohort study comparing patients who received early versus delayed or no PT intervention for occupational related injury. At 12-month follow-up the group who received early active physical therapy had significant reductions in amount of work time lost. Only 2% of patients who received early intervention went on develop chronic symptoms compared to 15% of the delayed treatment group.195 These findings have been supported numerous times.114, 128, 193, 225, 240, 304
MANUAL THERAPY
Thrust and non-thrust mobilization/manipulation is a common intervention utilized for acute, sub acute, and chronic low back pain. Despite its popularity, recent systematic reviews have demonstrated marginal treatment effect across the heterogeneous group of patients with low back pain.8, 9 Also, most trials have assessed the efficacy of mobilization/manipulation in isolation rather than in combination with active therapies. Recent research has
demonstrated that spinal manipulative therapy is effective for subgroups of patients, and as a component of a comprehensive treatment plan, rather than in isolation.
Research has determined a subgroup of patients likely to have dramatic changes with application of thrust manipulation to the lumbar spine, advice to remain active, and mobility exercise. Flynn conducted an initial derivation study of patients most likely to benefit from a general lumbopelvic thrust manipulation.96 Five variables were determined to be predictors of rapid treatment success, defined as a 50% reduction in Oswestry Disability Index scores within two visits. These predictors included:
• Duration of symptoms < 16 days
• No symptoms distal to the knee
• Lumbar hypomobility
• At least one hip with >35° of internal rotation
• FABQ work score < 19
The presence of 4 or more predictors increased the probability of success with thrust manipulation from 45% to 95%.
This test item cluster was validated by Childs et al,49 which demonstrated similar results with patients meeting four of the five predictors who received thrust manipulation (+LR 13.2, 95% CI=3.4, 52.1). Patients were randomized to receive either spinal manipulation or trunk strengthening exercises. Patients meeting the rule who received manipulation had greater reductions in disability than all other subjects. These results remained significant at 6
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month follow-up. A pragmatic rule has also been published to predict dramatic improvement looking at two factors:
• Duration < 16 days
• Not having symptoms distal to the knee
If these two factors were present, patients had a moderate-large shift in probability of a successful outcome following application of thrust manipulation (+LR= 7.2, 95% CI: 3.2, 16.1)102
An analysis of the outcomes associated with the Childs validation study demonstrated that when comparing patients who received manipulation and exercise versus those who received only exercise demonstrated less risk of worsening of disability in those patients who
received manipulation.48 Patient who received only exercise were eight (95% CI= 1.1–63.5) times more likely to experience a worsening of disability. The number needed to treat (NNT) with manipulation to prevent one additional patient from experiencing a worsening in disability was 9.9 (95% CI=4.9, 65.3).48
This rule has been further examined by Cleland with similar results for patients fitting the clinical prediction rule with two different thrust techniques, the previously utilized general lumbopelvic technique and a sidelying rotational technique.61 The two groups receiving thrust manipulation fared significantly better than a group receiving non-thrust mobilization at one week, 4 weeks, and 6 months.
The Cleland61 trial demonstrated that patient outcomes are dependent on utilization of a thrust manipulation, as those who received non-thrust techniques did not have dramatic improvement. This had previously been established by Hancock et al134 in a secondary analysis of patients who fit the clinical prediction rule that were treated primarily with non- thrust mobilization where no differences were found in a control group who received placebo intervention. The findings of the Cleland and Hancock papers demonstrate that rapid improvements associated with patients fitting the clinical prediction rule are specific to patients receiving thrust manipulation.
A secondary analysis by Fritz et al112 compared the effectiveness of a thrust manipulation and stabilization exercise intervention or stabilization intervention. The mean duration of symptoms for patients was 27 days (range, 1–594). Patients that were assessed to have lumbar hypomobility on physical examination demonstrated more significant improvements with the manipulation and exercise intervention than stabilization alone. Seventy-four percent of patients with hypomobility who received manipulation were deemed successful as compared to 26% of patients with hypermobility that were treated with manipulation. These findings may suggest that assessment of hypomobility, in the absence of contraindications, is sufficient to consider use of thrust manipulation as a component of comprehensive
treatment.
Beyond the success associated with the usage of thrust manipulation in patients with acute low back pain who fit the clinical prediction rule, there is evidence for the use of thrust manipulation in other patients experiencing low back pain. Aure and colleagues11
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demonstrated superior reductions in pain and disability in patients with chronic low back pain who received thrust manipulations when compared to an exercise intervention. More recently, Cecchi et al conducted a randomized controlled trial (n=210) in patients with low back pain.44 Subjects were randomized to receive thrust manipulation, back school intervention, or individualized physiotherapy intervention. Reductions in disability were significantly higher for the manipulation group at discharge and twelve months. Long term pain relief, reoccurrences of low back pain, and drug usage also favored the manipulation group.
Whitman et al311, 312 demonstrated that, for patients with clinical and imaging finding consistent with lumbar central spinal stenosis, a comprehensive treatment plan including thrust and non-thrust mobilization/manipulation directed at the lumbopelvic region is effective at decreasing pain and disability. In the randomized control trial, 58 patients were randomized to receive a comprehensive manual therapy approach, gluteal retraining, and body weight supported treadmill training or lumbar flexion exercises and traditional treadmill training.311 Seventy eight percent of patients receiving manual treatments met the threshold for success compared to 41% of the flexion based exercise group at six weeks. At long term follow-up all outcomes favored the experimental group, although these differences were not statistically significant. Manual therapy was delivered in a pragmatic impairment- based approach; specifically, 100% of patients received non-thrust mobilization to the lumbar spine, 50% of patients received thrust manipulation to the lumbar spine, and 31% of patients received lumbopelvic manipulation.12 Patients also received manual therapy interventions to other regions of the lower quarter and thoracic spine as deemed important by the treating therapists.12 This study supports the use of a comprehensive treatment program that includes manual therapy interventions in the management of patients with lumbar spinal stenosis.
Murphy et al218 published a prospective cohort study of 57 consecutive patients with central, lateral, or combined central and lateral lumbar spinal stenosis. Patients were treated with lumbar thrust manipulation, nerve mobilization procedures, and exercise. The mean improvement in disability, as measured by the Roland-Morris Disability Questionnaire, was 5.1 points from baseline to discharge, and 5.2 points from baseline to long term follow-up, satisfying the criteria for minimally clinical important difference. Pain at worst was also reduced by a mean of 3.1 points. Reiman et al,248 in a recent systematic review based off of the Whitman trial and several lower quality studies, recommends manual therapy techniques including thrust and non-thrust mobilization/manipulation to the lumbopelvic region for patients with lumbar spinal stenosis.
The hip has long been identified as a potential source of and contributor to low back dysfunction, and impairments in hip mobility have been found to be associated with the presence of LBP.19, 89, 249, 266, 318 It has been suggested that altered movements of the hip and spine may contribute to the development of low back pain, as it may alter the loads placed on the lumbar facets and posterior spinal ligaments.1, 190 Several authors have described restricted hip mobility in patients with low back pain as an indicator of positive response to interventions targeting the hip.33,44, 53,84,184,284,278,289 Some early evidence demonstrates successful incorporation of interventions targeting the hip into a more
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comprehensive treatment program for patients with lumbar spinal stenosis.278,279 Though research in this area is developing, clinicians may consider including examination of the hip and interventions targeting identified hip impairments for patients with LBP.
Clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain. Thrust manipulative and non-thrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with sub acute and chronic low back and back-related lower extremity pain.
TRUNK COORDINATION, STRENGTHENING, AND ENDURANCE EXERCISES
Lumbar strengthening and stabilization exercises are another commonly utilized treatment for LBP. These exercises are commonly prescribed for patients who have received the medical diagnosis of spinal instability.
In a Cochrane review on exercise therapy for the treatment of non-specific low back pain Hayden and colleagues140 examined the literature on exercise therapy for patients with acute (11), sub acute (6) and chronic (43) low back pain and reported that exercise therapy was effective in decreasing pain in the chronic population, graded activity improved absenteeism in the sub acute population, and exercise therapy is as effective as other conservative treatments or no treatments in the acute population. The larger criticism that the Cochrane reviewers found with the current literature was that the outcome tools were heterogeneous and the reporting was poor and inconsistent with the possibility of publication bias.
In a systematic review of 14 RCTs examining the effectiveness of motor control exercises for nonspecific LBP, Macedo et al200 concluded that motor control when used in isolation or with additional interventions is effective at decreasing pain and disability related to
nonspecific LBP. However, there was insufficient evidence to find motor control exercises superior to manual therapy or other exercise interventions. The authors were unable to provide recommendations regarding the best strategies for implementing motor control exercise into clinical practice.
A preliminary clinical prediction rule for the stabilization classification has been proposed to assist clinicians with accurately identifying patients that appear to be appropriate for a stabilization-focused exercise program.145 The clinical prediction rule for stabilization classification was developed using similar methodology for the manipulation rule. Variables that significantly predicted a 50% improvement in disability from LBP at 4-weeks in a multivariate setting were retained for the clinical prediction rule.145 Four examination findings:
• Age <40 years
• Positive prone instability test
• Presence of aberrant movements with motion testing
• SLR > 91 degrees
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were identified and a positive clinical prediction rule for stabilization was defined as presence of at least 3 of the findings (+LR = 4.0, 95% CI = 1.6, 10.0), while a negative clinical prediction rule was presence of fewer than 2 of the findings (−LR = 0.20, 95% CI = 0.03, 1.4).145 Validation of this test item cluster is required before it can be recommended for widespread clinical use.
Costa et al68 used a placebo-controlled randomized controlled trial to examine the use of motor control exercises in 154 patients with chronic LBP. Interventions consisted of either specific motor control exercises directed to the multifidus and transverse abdominis or non- therapeutic modalities. Short term outcomes demonstrated small but significant
improvements in favor of the motor control group for both patient activity tolerance and global impression of recovery. The exercise interventions failed to reduce pain greater than non-therapeutic modalities over the same period.
A randomized controlled trial was performed by Rasmussen-Bar et al246 that compared a graded exercise program, which emphasized stabilization exercises to a general walking program in the treatment of low back pain lasting greater than 8 weeks. At both the 12 months and the 36 months follow up the stabilization group outperformed the walking group with 55% of the stabilization group and only 26% of the walking group meeting the
predetermined criteria for success. This research demonstrates that a graded exercise intervention emphasizing stabilizing exercises seems to improve perceived disability and health parameters in short and long terms in patients with recurrent LBP.
Choi and colleagues51 performed a review of randomized clinically controlled trials that examined the effectiveness of exercise in the prevention of low back pain recurrence. This was published in a Cochrane review. Treatments were defined as exercise including
strengthening, endurance, and aerobic that occurred during the patient’s episode of care with a healthcare practitioner as well as those that occurred following discharge from a healthcare practitioner. Specific types of exercise were not assessed individually. The group found 9 studies that met their criteria for inclusion. There was moderate quality evidence that the number of recurrences was significantly reduced in two studies (Mean Difference −0.35;
95% CI −0.60 to −0.10) at one-half to two years follow- up. There was very low quality evidence that the days on sick leave were reduced in patients who continued to perform low back exercises following discharge (Mean Difference - 4.37; 95% CI −7.74 to −0.99) at one- half to two years follow-up. In summary, there was moderate quality evidence that post- discharge exercise programs can prevent recurrences of back pain.
In a randomized controlled trial, Hides et al149 compared a 4 week specific exercise training program to a control group consisting of advice and medication in a group of patients with first episode LBP. The specific exercise group performed co-contraction exercises believed to facilitate training of the lumbar multifidus and transverse abdominis muscle groups. The specific exercise group reported recurrence rates of 30% at one year and 35% at 3 years compared to 84% at 1 year and 75% at 3 years for the control group.
O’Sullivan et al226 completed a randomized controlled trial involving subjects with radiologically confirmed spondylolysis or spondylolisthesis. A specific exercise group
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received weekly interventions directed at specific training to promote isolation and co- contraction of the deep abdominal muscles and the lumbar multifidus. A control group received usual care typically consisting of aerobic exercise, rectus abdominis training and modalities. At the conclusion of the 10 week program, the specific exercise group demonstrated statistically significant improvements in both pain intensity and functional disability. These gains were maintained at a 30 month follow up.
Yilmaz and colleagues321 investigated the efficacy of a dynamic lumbar stabilization exercise program in patients with a recent lumbar microdiscectomy. In a randomized study they found that lumbar spinal stabilization exercises under the direction of a physical therapist was superior to performing a general exercise program independently at home and to a control group of no prescribed exercises at 3 months. This study had a small sample size with 14 in each group and did not describe any loss to follow up.
Kulig et al185 performed a randomized clinically controlled trial comparing an intensive 12- week exercise program and education to education alone and to usual physical therapy care post microdiscectomy. In the 2-group analyses, exercise and education resulted in a greater reduction in Oswestry Disability Index scores and a greater improvement in distance walked.
In the 3-group analyses, post hoc comparisons showed a significantly greater reduction in Oswestry Disability Index scores following exercise and education compared with the education-only and usual physical therapy groups. Limitations of this study included lack of adherence to group assignments and a disproportionate therapist contact time.
Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with sub acute and chronic low back pain with movement coordination impairments and in patients post lumbar
microdiscectomy.
CENTRALIZATION AND DIRECTIONAL PREFERENCE EXERCISES AND PROCEDURES A systematic review by Clare, et al59 reviewed 6 randomized/quasi-randomized controlled trials investigating the efficacy of McKenzie therapy in the treatment of spinal pain. The authors concluded that the studies suggest that McKenzie therapy is more effective than comparison treatments (NSAIDS, educational booklet, strengthening, etc.) at short-term follow-up. It should be noted that the studies in this review excluded trials where co- interventions were permitted and may not be generalizable to clinical practice. A second systematic review from Aina et al2 examined centralization of spinal symptoms. They reported centralization is a commonly encountered subgroup of low back pain, with good reliability during examination. Their meta-analysis resulted in a prevalence rate for centralization of 70% with sub-acute low back pain and 52% in chronic low back pain. The presence of centralization was associated with good outcomes and lack of centralization with poor outcomes. Macedo et al performed a systematic review and meta-analysis of 11 trials utilizing the McKenzie treatment approach.201 Short term results demonstrated improved outcomes compared to passive treatments. Long term follow-up at 12 weeks favored advice to remain active over McKenzie exercise, raising questions on the long term clinical effectiveness of the McKenzie methods for management of patients with low back pain.201
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Long and colleagues197 investigated whether a McKenzie examination and follow-up on 312 patients with acute, sub-acute, and chronic low back pain would elicit a directional
preference in these patients. Directional preference in this investigation was described as an immediate, lasting improvement in pain from performing repeated lumbar flexion,
extension, or sideglide/rotation spinal movements. Of the 312 patients, 230 participants (74%) had a directional preference, characterized as: extension (83%), flexion (7%), and lateral responders (10%). These patients were randomized into groups of 1) directional exercises matching the patient’s directional preference, 2) directional exercises opposite the patient’s directional preference, or 3) non-directional exercises. Significant reductions in pain, pain medication use, and disability occurred in the directional exercise group that was matched to their directional preference. One-third of the patients in the non-concordant exercise group dropped out because they were either not improving or worsening. The authors suggest that this study “adds further validity by demonstrating that a subject-specific treatment is superior to others in creating good outcomes.”197 One limitation of this study was that it only followed participants for two weeks post-intervention, thus, providing little insight into the long term effects of directional preference driven exercises.
Long and colleagues198 conducted a secondary analysis of a previous RCT examining a range of factors that predict a favorable outcome where patients were sub grouped based on the presence or absence of directional preference. The authors concluded from the analyses that those subjects who exhibited a directional preference or centralization response who then received a matched treatment had a 7.8 times greater likelihood of a good outcome, which was defined as a minimal reduction of 30% on the Roland-Morris Disability Questionnaire.
A multicenter randomized control trial by Browder et al35 looked to examine the effectiveness of an extension-oriented treatment approach in patients with low back pain.
The authors included a homogenous subgroup of patients that responded with centralization to extension movements. Forty-eight patients were randomly allocated to receive either exercise/mobilization promoting lumbar spine extension or lumbopelvic strengthening.
Subjects in both groups attended 8 physical therapy treatments and were given a home exercise program. The patients who received the extension-oriented treatment approach experienced greater reductions in disability compared to those subjects who received lumbopelvic strengthening exercises at 1 week, 4 weeks, and 6 months. The authors conclude that those patients that centralize with lumbar extension movements preferentially benefit from an extension-oriented treatment approach.
Werneke and colleagues309 performed a prospective, longitudinal cohort aiming to determine baseline prevalence of directional preference or no directional preference in 584 patients with non-specific low back pain who centralize, did not centralize, or could not be classified. The authors also sought to determine if these classifications predicted functional status and pain intensity at discharge. Therapists skilled in the use of the McKenzie methodology participated in the study. The authors found that the overall prevalence of directional preference and centralization was 60% and 41%, respectively. Results indicate that patients whose symptoms showed directional preference with centralization at intake reported better functional status and less pain compared to patients whose symptoms did not